HomeMy Public PortalAbout6267 AVON AVE_Electrical_8/15/1994_residential appliances WORKER'S COMPENSATION DECLARATION 20-0079 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
i�'t7ere4?y-affirm that I have a certificate of consent to self insure, 76A663
or`fc.ertificaie of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy t re6f(Sec.'3388800 Lab. C.) ,mss/ �(�f/(�.
Policy to. 2` Company r/1, � "� FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
LOCALITY
Certified co is filed with the count building inspection 1 &2-Family,Sq. Ft. $ $ SSdePar a . Multi-family 4 Ft
NEAREST
Date Applicant��� v Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. Ow ER
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAILs
permit is for one hundred dollars(5100)or less.) Total No. Additional P
I certify that in the performance of the work for which this permit CITY k\//tA9.1c�0_O✓Ift Tel.N '
is issued, I shall not employ any person in any manner so as t0 PLAN CHECK /Y
become subject-to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption, you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT >
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT U
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS P t-c
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. ��>�
(commencing with Section 7000) of Division 3 of the Business and CITYFkio Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. C }
Over 50 to 100 Incl. EGNNUM ER[ICESE OR Class. a
License Number '^� LIC.Class -( l 3 Over 100 DISTRICT NO. ROCESSED BY O
i / Services,Swbd.,MCC&Panelboards O� W_
�'{� FINAL
Contractor to , 'L Date t�( ` 0-399 Amp.Under 600 V DATE / _ O
ED I am exempt under Sec. VALIDATION 400-1000 Amp.Under 600 V W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason
BRANCH CIRCUIT FEES BY JL (n(j�J
Date: 15A,or 20A, 120V,Lighting or Recept. V lf_=.1 ,a Z
1 To 10 Branch Circuits ,t;° I =
Signature 11 To 40 Branch Circuits — _
❑ 41 Or More Branch Circuits `p!'.:
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits _
SINGLE FAMILY Temp.Power Pole&Appurtenances ''"T -_>_- " ���
HOME OWNER-BUILDER DECLARATION s
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit !HDCK 471 _L5
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuitsjr Aft CHI-+
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I7f3't;-i_^t� t; C:f
and Professions Code). �`01, )'r"I ` L.-V 74t
CONSTRUCTION LENDING AGENCY 65 t AN 9,�?�
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address f
I certify that I have read this application and under penalty of purjury state TOTAL FEE Jf
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the aboW
erty
for ection p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
MIA A,SIG R P E /